Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess?

BACKGROUND: Computed tomography scans have been used when cross-axial imaging is required to evaluate pediatric post-appendectomy abscesses. To reduce a source of radiation exposure, our institution converted to using contrast-enhanced magnetic resonance imaging to replace computed tomography scans in this clinical context. Our aim is to evaluate the performance of magnetic resonance imaging compared to computed tomography scans and associated clinical outcomes in this patient population. METHODS: A contrast-enhanced comprehensive magnetic resonance imaging protocol was implemented to evaluate a post-appendectomy abscess in 2018. A retrospective chart review was performed from 2015 to 2022 for pediatric patients (<18 years old) with prior appendectomy and subsequent cross-sectional imaging to evaluate for an intraabdominal abscess. Patient characteristics and clinical parameters between the 2 modalities were abstracted and compared using standard univariate statistics. RESULTS: There were a total of 72 post-appendectomy patients who received cross-axial imaging, which included 43 computed tomography scans and 29 magnetic resonance imaging during the study interval. Patient demographics were comparable between cohorts and rates of perforated appendicitis at the index operation (computed tomography: 79.1% vs magnetic resonance imaging: 86.2%). Missed abscess rate, abscess size, management technique, drainage culture results, readmission, and reoperation were similar between imaging modalities. Median request to scan time was longer for magnetic resonance imaging than computed tomography (191.5 vs 108 minutes, P = .04). The median duration of a comprehensive magnetic resonance imaging scan was 32 minutes (interquartile range 28-50.5 minutes). CONCLUSION: Contrast-enhanced magnetic resonance imaging provides an alternative cross-sectional imaging modality to computed tomography scans to evaluate pediatric post-appendectomy abscesses.

EAST multicenter trial of simulation-based team training for pediatric trauma: Resuscitation task completion is highly variable during simulated traumatic brain injury resuscitation.

BACKGROUND: Best practices for benchmarking the efficacy of simulation-based training programs are not well defined. This study sought to assess feasibility of standardized data collection with multicenter implementation of simulation-based training, and to characterize variability in pediatric trauma resuscitation task completion associated with program characteristics. METHODS: A prospective multicenter observational cohort of resuscitation teams (N = 30) was used to measure task completion and teamwork during simulated resuscitation of a child with traumatic brain injury. A survey was used to measure center-specific trauma volume and simulation-based training program characteristics among participating centers. RESULTS: No task was consistently performed across all centers. Teamwork skills were associated with faster time to computed tomography notification (r = -0.51, p < 0.01). Notification of the operating room by the resuscitation team occurred more frequently in in situ simulation than in laboratory-based simulation (13/22 versus 0/8, p < 0.01). CONCLUSIONS: Multicenter implementation of a standardized pediatric trauma resuscitation simulation scenario is feasible. Standardized data collection showed wide variability in simulated resuscitation task completion.

Understanding readmissions in children undergoing surgery: A pediatric NSQIP analysis.

BACKGROUND: Readmission is increasingly being utilized as an important clinical outcome and measure of hospital quality. Our aim was to delineate rates, risk factors, and reasons for unplanned readmission in pediatric surgery. MATERIALS AND METHODS: Retrospective review of pediatric patients (n=130,274) undergoing surgery (2013-2014) at hospitals enrolled in the Pediatric National Surgical Quality Improvement Program (NSQIP-P) was performed. Logistic regression was used to model factors associated with unplanned 30-day readmission. Reasons for readmission were reviewed to determine the most common causes of readmission. RESULTS: There were 6059 (n=4.7%) readmitted children within 30days of the index operation. Of these, 5041 (n=3.9%) were unplanned, with readmission rates ranging from 1.3% in plastic surgery to 5.2% in general pediatric surgery, and 10.8% in neurosurgery. Unplanned readmissions were associated with emergent status, comorbidities, and the occurrence of pre- or postdischarge postoperative complications. Overall, the most common causes for readmission were surgical site infections (23.9%), ileus/obstruction/gastrointestinal (16.8%), respiratory (8.6%), graft/implant/device-related (8.1%), neurologic (7.0%), or pain (5.8%). Median time from discharge to readmission was 8days (IQR: 3-14days). Reasons for readmission, time until readmission, and need for reoperative procedure (overall 28%, n=1414) varied between surgical specialties. CONCLUSION: The reasons for readmission in children undergoing surgery are complex, varied, and influenced by patient characteristics and postoperative complications. These data inform risk-stratification for readmission in pediatric surgical populations, and help to identify potential areas for targeted interventions to improve quality. They also highlight the importance of accounting for case-mix in the interpretation of hospital readmission rates. LEVEL OF EVIDENCE: 3.

Costs of Clostridium difficile infection in pediatric operations: A propensity score-matching analysis.

BACKGROUND: The purpose of this analysis was to assess the burden of Clostridium difficile infection in the hospitalized pediatric surgical population and to characterize its influence on the costs of care. METHODS: There were 313,664 patients age 1-18 years who underwent a general thoracic or abdominal procedure in the Kids' Inpatient Database during 2003, 2006, 2009, and 2012. Logistic regression was used to model factors associated with the development of C difficile infection. A propensity score-matching analysis was performed to evaluate the influence of C difficile infection on mortality, duration of stay, and costs in similar patient cohorts. Population weights were used to estimate the national excess burden of C difficile infection on these outcomes. RESULTS: The overall prevalence of C difficile infection in the sampled cohort was 0.30%, with an increasing trend of C difficile infection over time in non-children's hospitals (P < .001). C difficile infection was associated with younger age, nonelective procedures, increasing comorbidities, and urban teaching hospital status (P < .001). An estimated 1,438 children developed C difficile infection after operation. After propensity score matching, the mean excess duration of stay and costs attributable to C difficile infection were 5.8 days and $12,801 (P < .001), accounting for 8,295 days spent in the hospital and $18.4 million (2012 USD) in spending annually. CONCLUSION: C difficile infection is a relatively uncommon but costly complication after pediatric operative procedures. Given the increasing trend of C difficile infection among hospitalized surgical patients, there is substantial opportunity for reduction of inpatient burden and associated costs in this potentially preventable nosocomial infection.

Measuring Surgical Site Infections in Children: Comparing Clinical, Electronic, and Administrative Data.

BACKGROUND: Surgical site infections (SSIs) are an important end point and measure of quality of care. Surgical site infections can be identified using clinical registries, electronic surveillance, and administrative claims data. This study compared measurements of SSIs using these 3 different methods and estimated their implication for health care costs. STUDY DESIGN: Data were obtained from 5,476 surgical patients treated at a single academic children's hospital (January 1, 2010 through August 31, 2014). Surgical site infections within 30 days were identified using a clinical registry in the NSQIP Pediatric, an electronic surveillance method (Nosocomial Infection Marker; MedMined), and billing claims. Infection rates, diagnostic characteristics, and attributable costs were estimated for each of the 3 measures of SSI. RESULTS: Surgical site infections were observed in 2.24% of patients per NSQIP Pediatric definitions, 0.99% of patients per the Nosocomial Infection Marker, and 2.34% per billing claims definitions. Using NSQIP Pediatric as the clinical reference, Nosocomial Infection Marker had a sensitivity of 31.7% and positive predictive value of 72.2%, and billing claims had a sensitivity of 48.0% and positive predictive value of 46.1% for detection of an SSI. Nosocomial Infection Marker and billing claims overestimated the costs of SSIs by 108% and 41%, respectively. CONCLUSIONS: There is poor correlation among SSIs measured using electronic surveillance, administrative claims, and clinically derived measures of SSI in the pediatric surgical population. Although these measures might be more convenient, clinically derived data, such as NSQIP Pediatric, may provide a more appropriate quality metric to estimate the postoperative burden of SSIs in children.

Delayed Presentation of Jejuno-Jejunal Fistula With Stricture After Physical Child Abuse.

Small intestinal injury is seldom described in the context of child abuse. Signs and symptoms are subtle, often leading to delays in diagnosis. We describe a 3-year-old boy initially admitted with severe blunt abdominal trauma from physical child abuse. He was successfully managed nonoperatively. The child was then hospitalized several times for nonspecific abdominal symptoms until diagnostic laparoscopy discovered a jejunal stricture with a proximal jejuno-jejunal fistula. Symptoms fully resolved after resection. Delayed presentation of small intestinal injury should remain on the differential diagnosis in the evaluation of persistent abdominal symptoms in a child with a prior history of physical abuse, even if imaging studies do not reveal specific abnormalities.

An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis.

BACKGROUND: Recent efforts have been directed at reducing ionizing radiation delivered by CT scans to children in the evaluation of appendicitis. MRI has emerged as an alternative diagnostic modality. The clinical outcomes associated with MRI in this setting are not well-described. METHODS: Review of a 30-month institutional experience with MRI as the primary diagnostic evaluation for suspected appendicitis (n=510). No intravenous contrast, oral contrast, or sedation was administered. Radiologic and clinical outcomes were abstracted. RESULTS: MRI diagnostic characteristics were: sensitivity 96.8% (95% CI: 92.1%-99.1%), specificity 97.4% (95% CI: 95.3-98.7), positive predictive value 92.4% (95% CI: 86.5-96.3), and negative predictive value 98.9% (95% CI: 97.3%-99.7%). Radiologic time parameters included: median time from request to scan, 71 minutes (IQR: 51-102), imaging duration, 11 minutes (IQR: 8-17), and request to interpretation, 2.0 hours (IQR: 1.6-2.6). Clinical time parameters included: median time from initial assessment to admit order, 4.1 hours (IQR: 3.1-5.1), assessment to antibiotic administration 4.7 hours (IQR: 3.9-6.7), and assessment to operating room 9.1 hours (IQR: 5.8-12.7). Median length of stay was 1.2 days (range: 0.2-19.5). CONCLUSION: Given the diagnostic accuracy and favorable clinical outcomes, without the potential risks of ionizing radiation, MRI may supplant the role of CT scans in pediatric appendicitis imaging.

Endobronchial occlusion with one-way endobronchial valves: a novel technique for persistent air leaks in children.

PURPOSE: In children, persistent air leaks can result from pulmonary infection or barotrauma. Management strategies include surgery, prolonged pleural drainage, ventilator manipulation, and extracorporeal membrane oxygenation (ECMO). We report the use of endobronchial valve placement as an effective minimally invasive intervention for persistent air leaks in children. METHODS: Children with refractory prolonged air leaks were evaluated by a multidisciplinary team (pediatric surgery, interventional pulmonology, pediatric intensive care, and thoracic surgery) for endobronchial valve placement. Flexible bronchoscopy was performed, and air leak location was isolated with balloon occlusion. Retrievable one-way endobronchial valves were placed. RESULTS: Four children (16 months to 16 years) had prolonged air leaks following necrotizing pneumonia (2), lobectomy (1), and pneumatocele (1). Patients had 1-4 valves placed. Average time to air leak resolution was 12 days (range 0-39). Average duration to chest tube removal was 25 days (range 7-39). All four children had complete resolution of air leaks. All were discharged from the hospital. None required additional surgical interventions. CONCLUSION: Endobronchial valve placement for prolonged air leaks owing to a variety of etiologies was effective in these children for treating air leaks, and their use may result in resolution of fistulae and avoidance of the morbidity of pulmonary surgery.

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy.

BACKGROUND/PURPOSE: Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA). METHODS: IRB-approved retrospective review (September 2010-July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospital's cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis. RESULTS: There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0h, p<0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p=0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of $1378 relative to MLA (p=0.009). CONCLUSIONS: In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.

Collaborating to increase access to clinical and educational resources for surgery: a case study.

A case study is described in which collaborations between a Department of Surgery, a Department of Information Technology, and an academic health sciences library resulted in the development of an electronic surgical library available at the bedside, the deployment of tablet devices for surgery residents, and implementation of a tablet-friendly user interface for the institution's electronic medical record.

Isolated pediatric pancreatic transection secondary to ocean-related trauma.

CONTEXT: Isolated pancreatic transection is a rare but well-recognized complication following blunt trauma of the abdomen. Diagnosis at presentation may be difficult and delayed due to subtle initial symptoms and evolving nature of the injury. CASE REPORT: We describe an isolated complete pancreatic transection in a 14-year-old female secondary to a previously unreported and highly unusual mechanism (being tossed by a wave). Diagnosis was obtained by computed tomography scan 24 hours following initial trauma. She was managed operatively with an open distal pancreatectomy with splenic preservation and no subsequent complications. CONCLUSIONS: The force sustained from the blunt abdominal trauma of being tossed by a wave can be significant. The management of pancreatic injuries in children, particularly in the context of ductal transection, is controversial. Timely recognition and management is critical to optimal outcomes. Early operative intervention may help to avoid complications such as abscess or pseudocyst formation.

Use of computed tomography to categorize the type of tracheal agenesis.

We report a case of type I tracheal agenesis with vertebral defects, anal atresia, tracheoesophageal fistula and/or esophageal atresia, radial dysplasia, renal defects, and cardiovascular defects association in which computed tomography was helpful in categorizing the diagnosis. This rare and fatal condition should always be considered when confronted with a neonate impossible to resuscitate at birth.

The ectopic appendicolith from perforated appendicitis as a cause of tubo-ovarian abscess.

Acute appendicitis is a common surgical cause of abdominal pain in the pediatric population. History and physical examination are atypical in up to a third of patients. Known potential complications of untreated or delayed management of acute appendicitis include appendiceal perforation, periappendiceal abscess formation, peritonitis, bowel obstruction and rarely septic thrombosis of mesenteric vessels. We report an unusual complication of perforated appendicitis. A tubo-ovarian abscess developed secondary to appendicolith migration into the right fallopian tube in a patient who had undergone interval laparoscopic appendectomy for perforated appendicitis. The retained appendicolith was visualized within the obstructed and dilated fallopian tube on contrast-enhanced CT. We discuss the CT imaging features of this unusual complication of perforated appendicitis.